[show abstract][hide abstract] ABSTRACT: Partial orchiectomy is becoming more accepted for indications such as a metachronous germ cell tumor due to reported oncological control, and minimal functional, physical and psychological morbidity. Most data originate from Europe. Thus, we reviewed our North American experience with such men who underwent partial orchiectomy for a presumed contralateral testicular malignancy.
We identified demographic, clinical, pathological and outcome data on men in our institutional database who underwent partial orchiectomy for presumed testicular malignancy from 1994 to 2009 and had a prior germ cell tumor. Patients were followed with examination, markers and imaging.
We identified 27 men, of whom 17 (63%) had malignancy, including seminoma in 9, teratoma in 3, embryonal lesion in 1, Leydig cell tumor in 3 and carcinoma in situ in 1, and 10 (37%) had benign lesions. Frozen section was accurate, no positive margins were reported and all tumors were stage 1. Carcinoma in situ was found in 9 patients (53%). No perioperative complications were recorded. Management after partial orchiectomy was observation in 12 of 17 cases. Two patients underwent completion orchiectomy for local recurrence of carcinoma in situ only, including chemotherapy in 1. A patient with seminoma elected radiation and 1 required retroperitoneal lymph node dissection for teratoma. The remaining 5 patients with carcinoma in situ were surveilled. Of the men 31% required testosterone substitution. All patients were disease free at a median 5.7-year followup with no local recurrences.
Partial orchiectomy is an option to decrease morbidity in men with a metachronous germ cell tumor. Clearly a definite benefit of partial orchiectomy is that a significant proportion of patients with suspicious testicular lesions did not have malignancy and were definitively treated with an organ sparing approach. However, partial orchiectomy is potentially associated with the need for adjuvant treatment and androgen substitution, which should be discussed with all patients.
The Journal of urology 02/2011; 185(2):508-13. · 4.02 Impact Factor
[show abstract][hide abstract] ABSTRACT: Organ-sparing approaches are currently practiced in urology for many malignancies. Partial orchiectomy of germ cell tumors (GCT) provides potential benefits over radical surgery by reducing the need for androgen substitution, lessening psychological stress, and preserving fertility, with a durable cure rate. Furthermore, many testicular lesions detected clinically or by ultrasonography will be benign, in which case radical orchiectomy represents overtreatment. Partial orchiectomy for benign lesions allows preservation of endocrine and exocrine function, and reduced risk of local recurrence. However, selection criteria are not clear and one must always be suspicious that a GCT might exist. Carcinoma in situ that remains in the salvaged testicle is a challenge to treat. Radiation therapy is an option, although there is a high chance that patients will subsequently require hormonal replacement. Partial orchiectomy should be undertaken only in selected patients--men with bilateral testicular cancer or GCT in a solitary testis--if the size and location of the mass are amenable to surgery. Informed patient consent discussing radical orchiectomy as the gold standard is mandatory, and discussion of the risks associated with CIS and its treatment, as well as the need for androgen supplementation are paramount. Alternative strategies of organ preservation, such as radiotherapy, HIFU and chemotherapy, might be appropriate treatment options in the future. However, the safety and efficacy of these procedures needs to be demonstrated in comparison with partial orchiectomy in larger and prospective studies with longer follow-up.
[show abstract][hide abstract] ABSTRACT: Active surveillance, primary retroperitoneal lymph node dissection and adjuvant chemotherapy are treatment options for high-risk clinical stage (CS) I nonseminomatous germ cell testicular tumors (NSGCT). Since 1981, at Princess Margaret Hospital, Toronto, initial active surveillance with treatment delayed until relapse has been the preferred management option for all CS I NSGCT, regardless of baseline risk of relapse which has allowed us to better define and assess the natural history of high-risk tumors.
From 1981 to 2005, 371 patients with CS I NSGCT were placed on an active surveillance protocol. Recurrence patterns, predictors of relapse, disease specific (DS) and overall survival (OS) were measured. Outcomes were stratified into two cohorts by their time of diagnosis [initial, 157 patients (1981-1992); recent, 214 patients (1993-2005)].
Median follow-up was 6.3 years. Median time to relapse was 7.1 months. Lympho-vascular invasion (P < 0.0001) and pure embryonal carcinoma (P = 0.02) were independent predictors of relapse. In the initial cohort, 66/157 (42.0%) were high-risk and 36/66 (54.5%) relapsed versus 17/91 (18.7%) low-risk (P < 0.0001). In the recent cohort, 59/214 (27.6%) patients were high-risk and 29/59 (49.2%) recurred, versus 22/155 (14.2%) low-risk (P < 0.0001). The 5-year DSS and OS were 99.2 and 98.2%, respectively.
Nonrisk adapted active surveillance is the preferred management strategy for all CS I NSGCT patients including those at high-risk, providing near 100% cure rate with reduced overall treatment burden. Approximately half of the high-risk patients will be spared unnecessary treatment with little or no increase risk.
World Journal of Urology 08/2009; 27(4):441-7. · 2.89 Impact Factor
[show abstract][hide abstract] ABSTRACT: Renal cell carcinoma (RCC) is the most common malignancy of the kidney. Despite widespread treatment at diagnosis, overall mortality rates associated with RCC have not decreased. Partly because of the more frequent use of abdominal imaging, diagnosis as an incidental finding has increased. The largest increase in incidence is in tumors smaller than 4 cm, termed small renal masses (SRMs). SRMs that are RCC may frequently be growth slowly and have a low risk of early progression. Initial active surveillance with delayed treatment for progression for selected patients should be considered. This should result in an overall decrease in treatment burden and cost saving.
Urologic Clinics of North America 12/2008; 35(4):627-34; vii. · 1.39 Impact Factor